Focal

Therapy for Brain Lesions

By: Veronica Chiang

Focal options today:
1. Surgery
a. Need for diagnosis, need fro decompression, single lesion and best
treatment option available
b. Neurosurg dogma: if theres one lesion, then take it out is now
changing and becoming of a more thoughtful process
c. Indications for surgery for metastatic disease has diminished
2. Stereotactic radiosurgery (GKRS)
a. Single fraction high dose radiation dose to cover most of tumor with
highly collimated (rapid fall off) at edges of lesion
i. How fast it falls off depends on Collimater size, tumor size
ii. For example: acoustic schwannoma uses smaller collimaters
because want to minimize radiation to this patient who will
live longer
b. Each collimator gives less radiation than whats in air, but when you
multiply it by 200 collimaters in the headpiece, then you have super
localized radiation
c. GKRS first originated for functional purposes
d. Dosemetrist are mapping XYZ coordinates of the target and to
position the patient
e. Frame guarantees accuracy
3. Updated LINAC
a. Rotation to best target lesion
b. Smaller the leaver=precision
c. Faster the leaves= greater frequency of therapy delivery
d. Treatments ~20minutes, setup takes ~ hour
e. Patient wears a very hard fitting frame that is so tight that it
sometimes causes ulcers
4. Trials:
a. JROSG 99-1: SRS alone vs SRS+WBRT
i. Largest multi-institutional RCT
ii. 1-4 BMets, less than or equl to 3cm diameter. KPS greater than
70
iii. aborted 75% accrual
iv. no difference of efficacy based on histology
v. no diff in toxicity
5. Radiosurg alone as 1st line treatment?
a. Radiosurg alone provides excellet local control response and
durability as opposed to WBRT
b. Faster resolution of symptoms
c. Well tolerate one-day procedure.
d. Almost no side effects: headaches and possible seizure threshold
adjustment

e. Conclusion: Radiosurgery alone prolly provides equivalent functional

and survival outcome compared to resection+WBRT for single lesion
6. Cost to Whom of radiosurgery:
a. GKRS is 2x expensive as WBRT
b. Adding WBRT to SRS decreased quality life months by 1.2
7. NeuroBlate
a. Buffer around the lesion being GKRS: Protein line (safety), cell death
line
8. LITT
a. Burning of tumors, have been seeing great responses. Even being used
on meningiomas and epilepsy now